HQSC Serious and Sentinel Events Report 2011/12

The Health Quality & Safety
Commission has released the 2011/12 report of serious and
sentinel events (SSEs) in District Health Board hospitals.

The report shows 360 SSEs were reported, 3 percent
fewer than the 3701 recorded in 2010/11. Ninety-one patients
died (86 in 2010/11), although not necessarily as a result
of the adverse event which occurred.

Adverse events
reported by DHBs for 2011/12 include:

•
170 falls, a 13 percent decrease from the 195 falls reported
the previous year, and the first decrease since reporting
began. Falls represent 47 percent of all SSEs reported for
2011/12• 111 clinical management events, up
from 105 in 2010/11. These represent 31 percent of all SSEs
reported for 2011/12, and include 17 cases of delayed
treatment due to failures in hospital systems – an
increasing trend• 18 medication errors, down
from 25 the previous year. These represent 5 percent of all
SSEs for 2011/12• 17 suspected in-patient
suicides, up from three the previous year. These represent
5 percent of all SSEs for 2011/12.

The
Commission’s Chair, Professor Alan Merry, says not all the
events described in the report were preventable, but many
involved errors that should not have happened.

“In
some tragic cases errors resulted in serious injury or
death. Each event has a name, a face and a family, and we
should view these incidents through their eyes.”

Professor Merry welcomes the overall decrease in SSEs
and specifically falls for 2011/12.

“This is very
good news and represents a lot of hard work by DHBs to both
report and prevent adverse events,” he says.

“At
the same time, however, we have seen an increase in the
number of cases of delayed treatment and suspected
in-patient suicides.”

He says the greater number
of suspected in-patient suicides this year does not appear
to be part of an increasing trend. Most of the cases
involved mental health patients, although at least two were
patients who had been on general wards.

“The
Commission has looked at the reviews into these very sad
events and there appear to be no common factors. There is
also no evidence of a trend of increasing in-patient
suicides.”

Over the past five years, in-patient
suicide numbers have varied – 16 in 2007/08, 8 in 2008/09,
4 in 2009/10, 3 in 2010/11 and 17 in 2011/12.

The
Commission’s Reportable Events Clinical Lead, Dr David
Sage, says the cases involving delays emphasise two things
– how important it is for clinicians to follow up when
tests have been ordered, referrals made, or further
treatment recommended; and the importance of formal
reconciliation procedures when organising biopsies and
appointments.

“The Commission is looking at
measures that can be put in place to reduce the likelihood
of these types of events. For example, making sure patients
are full partners in the management of their care – so
they too are aware if there needs to be a further test,
result from a specimen, or referral to another
specialist,” says Dr Sage.

Professor Merry says
despite the gains made in 2011/12, too many people are still
being harmed in the course of receiving health care.

“This is not about apportioning blame,” he says.
“This is about learning from our mistakes and making our
health and disability services safer so patients receive the
care they need, without needless harm. This SSE report
contributes to that by stimulating discussion about adverse
events and identifying areas for improvement.”

The
2011/12 SSE report is the Commission’s third, and the
sixth by DHBs. It does not include all adverse events that
occurred in public hospitals, only those which DHBs consider
serious or sentinel.

This year, a national
reportable events policy has introduced a change to the way
SSEs are reported to the Commission. Previously, there was
no requirement for DHBs to report the outcome of a review to
the Commission, meaning lessons from events were often not
shared. There is now a requirement for organisations to
report to the Commission the key findings and
recommendations of reviews of events that occurred from 1
July 2012. Future SSE reports will be able to discuss in
greater detail issues such as contributory causes and what
has been learnt from the events.

In addition, a
number of health and disability organisations other than
DHBs are in discussion with the Commission about potentially
reporting SSEs in the future. They include members of
organisations such as the Disability Support Network, Care
Association NZ, Hospice NZ and Ambulance NZ. Individual
providers such as Mercy Hospital Dunedin are also in
discussions with the Commission.

The Commission is
working with the mental health sector to identify the best
approach to reviewing and reporting on suicides involving
mental health service users, and in future there will be a
separate report covering these events.

The
Commission is also working closely with the health and
disability sector on a number of initiatives, including a
national patient safety campaign to be launched in the first
half of 2013.

SSE results for individual DHBs are
posted on DHB websites. For a copy of the full report,
summary document, and questions and answers about SSEs,
visit www.hqsc.govt.nz.

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